Exam 2: weeks 4 & 5 Flashcards
What is the priority in mental health emergency care
Perform triage and stabilization
What is triage
Determines the severity of the problem and the urgency of a response
What is stabilization
The resolution of the immediate crisis
What is primary prevention
Applies to general public; reduces risk of disease
What is secondary prevention
Applies to susceptible population before any symptoms occur; screening and early id of problems
What is tertiary prevention
Applies to symptomatic patients; reduce complications or disability
When discharging a patient to outpatient services, what are some things that can affect treatment success
Housing stability
income
support system
substance abuse
physical well-being
What are the criteria to being admitted to an inpatient psychiatric unit
patients who re…
- suicidal
- homicidal
- extremely disabled and need acute care
What is the clinical pathway
The essential steps of caring for patients with specific issues based on evidence-based healthcare techniques
What is milieu
The setting in which something occurs
What are the characteristics of a therapeutic milieu
A safe environment where patients can work with staff to take control of their own mental health and well-being
What are the different outpatient psychiatric care settings
community mental health centers
home care
assertive community treatment (ACT)
intensive outpatient programs (IOP)
partial hospitalization programs (PHP)
telepsychiatry
mobile mental health bus
what are community mental health care centers
places where people with limited access to private healthcare can go for help
What is assertive community treatment (ACT)
Designed for those who have had frequent hospitalizations for mental health crises
What is mobile mental health
An emergency service for those who need stabilization out in the community
What are the six principles of bioethics
autonomy: patient rights
beneficence: promote good
nonmaleficence: do no harm
justice: equality of care
fidelity: loyalty
veracity: telling the truth
What is pharmacogenetic testing
A DNA test to see which antidepressants are most likely to work
- not FDA approved because of lack of clinical evidence
- aims to decrease trial and error approach
- aims to decrease recovery time between medications
- stigmatization could lead to someone losing job oppurtunities
What does “writ of habeas corpus” mean
A formal written order to free a person (from a mental institution)
- a patient who believes they are being held unjustly can petition for this
What are the four different discharge procedures from a mental health organization
- unconditional release
- conditional release
- release against medical advice (AMA)
- assisted outpatient treatment
What is an unconditional release
Patient is released from the hospital; can be court ordered or facility ordered
What is a conditional release
Patient is released on the condition of attending outpatient treatment for a specified amount of time
What is release against medical advice (AMA)
When treatment is beneficial for the patient but they are no longer a threat to themselves or others. There is no reason to hold them involuntarily so legally, the patient can leave when they wish
What is assisted outpatient treatment
Patient is released on the condition of a COURT ORDERED outpatient treatment regimen
What are the patients rights
- right to treatment
- right to refuse treatment
- right to informed consent
- right to psychiatric advance directives
- rights regarding isolation and restraints
- right to confidentiality
What is informed consent
patient must be informed of the risks and benefits and alternatives of any treatment and must consent to the treatment
- must be capable of making decisions
- must be competent enough to make decisions
- implied consent is also included
What are a patients rights when it comes to isolation and restraints
- Must have an order and documentation
- in an emergency, a nurse may place a patient in restraints or isolation but must obtain an order immediately after
- orders are never written as PRN or standing orders
- includes chemical, physical, and seclusion restraints
- chemical restraints are the least restrictive
What are some exceptions to the rule of confidentiality
- duty to warn and protect third parties
- duty to report elder and child abuse
What is a tort
any wrongful act that results in injury to another
What are the intentional torts that nurses commit
- assault
- battery
- false imprisonment
- invasion of privacy
- defamation of character (slander/libel)
What are the unintentional torts that nurses commit
- negligence
- malpractice
What are the five elements needed to prove negligence
- duty
- breach of duty
- cause in fact: did the negligence cause the injury
- proximate cause: was the injury foreseeable
- damages
What is forensic nursing
A nurse who works at a court and explains the science of nursing to the judge and jury. The nurse will determine:
- patient competency
- if someone is fit to stand trial
- if they need to be involuntarily committed
- if they were responsible for the crime
What are the symptoms of mood dysregulation disorder
Seen in children (usually males)
- constant severe irritability and anger
- temper tantrums out of proportion to the situation
How do we treat mood dysregulation disorder
- medications based on symptoms (antidepressants, stimulants (ADHD), or anti anxiety)
- cognitive behavioral therapy
- parental training in facial expression recognition
What is persistent depressive disorder
Formerly known as dysthymia
- low level depressive feelings most of the day for most days
- for 2 years for adults
- for 1 year for adolescents
What are the symptoms of persistent depressive disorder
- Decreased appetite or overeating
- insomnia or hypersomnia
- low energy
- poor self-esteem
- difficulty thinking
- hopelessness
What is premenstrual dysphoric disorder
symptoms that occur the week before a person’s menstrual cycle. Symptoms decrease or disappear at the onset of their period and menopause.
What are the symptoms of premenstrual dysphoric disorder
- Mood swings
- irritability
- depression
- anxiety
- feeling overwhelmed
- difficulty concentrating
What is the treatment for premenstrual dysphoric disorder
FDA approved
- drospirenone and ethinyl estradiol contraceptives
- SSRIs
What are the symptoms of major depressive disorder
- depressed mood
- anhedonia (loss of interest or pleasure)
- appetite changes
- weight changes
- sleep disturbances
- worthlessness/guilt
- unable to concentrate
- psychomotor agitation
What are the risk factors for getting major depressive disorder
- genetic (immediate family members)
- biochemical (stressful life events)
- hormonal
- inflammatory (not directly but research suggests it plays a role)
- cognitive (early life experiences cause irrational thoughts when going through stressful situations later)
- gender (female)
- other mental disorders
- substance abuse
- chronic medical conditions
What is the mnemonic used to assess a patient for depression
SIG E CAPS
S- sleep disturbance
I- interest decreased
G- guilty feelings
E- energy decreased
C- concentration decreased
A- appetite changes
P- psychomotor function decreased
S- suicidal ideations
What are the three phases of the implementation step of the nursing process for mental health
- acute phase
- continuation phase
- maintenance phase
What does the acute phase of implementation include
6-12 weeks
- initial treatment
- need 4-6 weeks to see if the treatment is working for them
What does the continuation phase of implementation include
4-9 months
- continue treatment
- monitor for signs of relapse
- monitor for side effects
What does the maintenance phase of implementation include
1 year +
- continue treatment
- monitor for signs of relapse
Which class of medications are most commonly prescribed for major depressive disorder
SSRIs
What are some examples of SSRIs
- citalopram(Celexa)
- escitalopram(Lexapro)
- fluoxetine (Prozac)
- paroxetine (Paxil)
- sertraline (Zoloft)
Why are SSRIs the first-line treatment for major depressive disorder
- low instance of anticholinergic side effects
- low cardiotoxicity
- fast onset (compared to other classes)
- patient compliance is better
- also good for anxiety and dysphoria
What are the side effects of SSRIs
- agitation
- sleep disturbance
- tremor
- anorgasmia
- headache
- dry mouth
- sweating
- weight change
- mild nausea
- loose bowel movements
- central serotonin syndrome (CSS)
What are the symptoms of serotonin syndrome
- abdominal pain
- diarrhea
- sweating
- fever
- tachycardia
- elevated BP
- delirium
- myoclonus (incoordination/ rigidity)
- irritability
- hyperpyrexia (extremely high fever > 41 C (105.8 F)
- cardiovascular shock
What are some SNRI drugs
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor)
- desvenlafaxine (Pristiq)
- levomilnacipran (Fetzima)
What is the difference between an SSRI and an SNRI
- same side effects
- Serotonin reuptake inhibition vs. serotonin and norepinephrine reuptake inhibition
- SSRIs are tolerated better
How do tricyclic antidepressants work
Block the reuptake of serotonin and norepinephrine at the presynaptic neuron
- takes 10-14 days to work
- therapy continued 6-12 months to prevent relapse
- starts at a low dose then increases
What are the side effects of tricyclic antidepressants
- anticholinergic effects
- cardiac dysrhythmias
- tachycardia
- myocardial infarction
- heart block
What are anticholinergic effects
- dry mouth
- blurred vision
- tachycardia
- orthostatic hypotension
- constipation
- urinary retention
- esophageal reflux
When taking tricyclic antidepressants, what other drugs should you avoid
- MAOIs
- phenothiazines
- barbiturates
- disulfiram
- oral contraceptives
- anticoagulants
- benzodiazepines
- alcohol
- nicotine
- some antihypertensives
When would someone be prescribed an MAOI
- unconventional depression
- anxiety disorders
What things should be avoided when taking MAOIs
foods containing tyramine, tryptophan, and foods that affect dopamine
What are some MAOI drugs
- Isocarboxazid (Marplan)
- Phenelzine (Nardil)
- Selegiline
- Tranylcypromine
What are the side effects of MAOIs
- orthostatic hypotension
- weight gain
- edema
- change in heart rate and rhythm
- constipation
- urinary hesitancy
- vertigo
- hypomanic or manic behavior
- insomnia
- weakness
- fatigue
What are the classes of drugs used to treat major depressive disorder
- SSRIs
- SNRIs
- TCAs
- MAOIs
- SARIs
- NDRIs
- NaSSA
What are the two newest drugs used for major depressive disorder
Esketamine: NMDA antagonist
Brexanolone (Zulresso): only FDA approved drug for post-partum depression
What are some non-pharmacological treatments for major depressive disorder
- Electroconvulsive therapy (ECT)
- Repetitive Transcranial magnetic stimulation
- Vagus nerve stimulation
- Deep brain stimulation
- Light therapy
- St. John’s wort
- Exercise
What is electroconvulsive therapy
- sends electricity through the brain causing a seizure
- used when other methods are not working
- side effects include confusion, disorientation, and short-term memory loss
What is repetitive transcranial magnetic stimulation
- use MRI strength magnets to stimulate the cerebral cortex
- non-invasive
- metal in head is a contraindication
- side effects include headache, lightheadedness, scalp tingling/discomfort, seizure (rarely)
What is vagus nerve stimulation
- originally used to treat epilepsy
- electrical stimulation to decrease seizures and boost mood by increasing neurotransmitter levels
- side effects include Voice alteration, Neck pain, cough, paresthesia, and dyspnea
What is deep brain stimulation
- surgically implanted electrodes in the brain
- stimulates regions seen to be underactive in depression
- FDA approved for parkinson’s and OCD but off label for MDD
What is light therapy
- first line treatment for seasonal affective disorder
- special light is pointed at persons face for 30 minutes each day
- negative effects are headache and jitteriness
What is St. John’s wort
- herbal supplement said to help depression
- not FDA approved
- dosing variable
- interacts with lots of other drugs
What are the different levels of anxiety
- mild anxiety
- moderate anxiety
- severe anxiety
- panic
What are the characteristics of mild anxiety
- everyday problem solving
- grasp information effectively
- slight discomfort: fidgeting, nail-biting
What are the characteristics of moderate anxiety
- selective inattention
- clear thinking impaired
- poor problem solving
- sympathetic nervous system symptoms such as tension, pounding heart, increased pulse and respiration rate, diaphoresis,
What are the characteristics of severe anxiety
- inattention greatly increased
- difficulty concentrating on environment
- confused, automatic behavior
- problem solving not possible
- sympathetic symptoms increase
- sense of doom
What are the characteristics of panic
- disturbed behavior (running, screaming, pacing)
- loss of touch with reality
- impulsive behaviors
What are defense mechanisms
Automatic psychological processes that protect a person from anxiety and awareness of internal or external dangers
What are the 6 defense mechanisms
- repression
- denial
- projection
- displacement
- regression
- sublimation
What is repression
unconscious exclusion of unpleasant experiences
What is denial
ignoring things that cause you anxiety
What is projection
Putting unwanted thoughts about yourself on others (a cheating person accuses their spouse of cheating)
What is displacement
Taking stressors out on non-threatening person (boss yells at you at work so you go home and kick your dog)
What is regression
Reverting to childlike behavior when stressed (sucking your thumb)
What is sublimation
transforming negative impulses to positive actions (angry at dad, punches punching bag instead of him) (person wants to inflict pain on people, becomes a dentist)
What is separation anxiety disorder
- inappropriate level of concern when separated from a significant other
- fear that something terrible will happen
- typically diagnosed prior to age 18
What are the most common phobias
- dogs
- spiders
- heights
- storms
- water
- closed spaces
(tends to run in the family)
What are the most common phobias
- dogs
- spiders
- heights
- storms
- water
- closed spaces
(tends to run in the family)
What is social anxiety disorder
severe anxiety caused by a social or performative expectation that will be looked at negatively by others
What is social anxiety disorder
severe anxiety caused by a social or performative expectation that will be looked at negatively by others
What is panic disorder
recurrent, sudden, unexpected panic attacks
symptoms include:
- terror
- limited perceptual field
- severe personality disorganization
What is agoraphobia
Fear of being in an environment or situation where escape is difficult
(e.g., being alone outside; being home alone; traveling in a car, bus, or plane; being on a bridge or in an elevator).
What is generalized anxiety disorder
Excessive worry that lasts for months
- out of proportion of what’s happening
- constantly anticipate disaster
- females 2X more than males
What are some symptoms of generalized anxiety disorder
- sleep disturbances
- irritability
- tense muscles
What is substance-induced anxiety disorder
Anxiety brought on by use of a substance or within a month of stopping use of a substance.
(alcohol, heroin, cocaine, hallucinogens)
What are some things that cause anxiety
- genetics
- depression
- other medical conditions
What are somatic symptoms of anxiety
- sensation of choking
- feeling smothered
- numbness/tingling
What are some cognitive symptoms of anxiety
- fear of dying
- offensive body processes
- fear of witchcraft (cultural)
- fear of magic (cultural)
What is an obsession
Thought, impulses, or images in the mind that won’t go away
What is a compulsion
ritualistic behaviors that are done in order to reduce anxiety or to stop something bad from happening
What are the different types of obsessive compulsive disorders
- body dysmorphic disorder
- hoarding disorder
- Trichotillomania
- Excoriation disorder
- Substance-induced obsessive-compulsive and related disorders
- Obsessive-compulsive or related disorder due to a medical condition
What is body dysmorphic disorder
A preoccupation with an imagined or defective body part
- mirror checking
- camouflaging
- overwhelming feelings of disgust
- fear of rejection by others
- usually involves weight, facial features, stomach, breasts/chest
What is hoarding disorder
Obsessively accumulating things that may or may not be valuable to the person.
- usually have depression, social phobia, GAD, and/or ADHD
- letting go of any object is painful
- collecting consumes their life
- person is alienated
What is Trichotillomania
Obsessive hair pulling
What is excoriation disorder
Obsessive skin-picking
What are some risk factors for OCD
- child abuse
- trauma
- post-infectious autoimmune syndrome
- genetics
- anxiety disorders
- eating disorders
- tic disorders
What is post-infectious autoimmune syndrome
An infection causes an autoimmune response that attacks the brain which causes encephalopathy and affects thoughts and behaviors
What classes of drugs are prescribed for anxiety disorders
- SSRIs: first choice
- SNRIs: also very helpful
- TCA: clomipramine
- MAOIs: only for resistive disorders (not usual)
- Benzodiazepines: addictive, short term
- BuSpar: not addictive but takes 2-4 weeks to work
- other: beta-blockers, antihistamines, anticonvulsants (according to other health issues)
Which drugs are commonly prescribed to children with OCD
- fluoxetine (SSRI)
- fluvoxamine (SSRI)
- sertraline (SSRI)
- clomipramine (TCA)
What are some brain-based therapies for OCD
Gamma knife: creates lesions to form a disconnect of overactive pathways
Deep brain stimulation: implanted electrodes use electricity to reduce symptoms
What is the goal of cognitive behavioral therapy in treating OCD
- exposure to triggers
- show that anxiety does resolve even when ritual is not completed
What is the flooding technique
Exposing someone with OCD to large amounts of their triggers in order to extinguish the response
What are some risk factors for suicide
- depressive disorders
- schizophrenia
- alcoholism
- substance abuse
- borderline personality disorder
- antisocial personality disorder
- panic disorder
- male gender
- genetics
- aging
- physical health issues
Why are adolescents at a higher risk of commiting suicide
Immature prefrontal cortex; controls executive functions such as:
- judgement
- frustration tolerance
- impulse control
What are you looking for when you assess for risk of suicide
- verbal clues
- nonverbal clues
- lethality of the plan
- history of attempts
- family history
- sudden switch from sad to happy mood
- social supports
What are overt statements
Statements about death and dying
“life just isn’t worth living anymore”
What are covert statements
Statements that aren’t directly about death or dying but are still ominous
“I won’t be a problem much longer”
“how do I donate my body to science”
“things will never work out”
What are some behaviors to look put for when assessing a patient for suicide
- giving away prized possessions
- withdrawing
- making final arrangements
- sudden unexplained recovery from hopelessness
What scale is used to assess for suicide
SAD PERSONS
S - sex (male)
A - age (25-44 or 65+)
D - depression
P - previous attempt
E - ethanol use
R - rational thinking loss
S - social support (lacking or loss)
O - organized plan
N - no spouse
S - sickness
What are some “hard” methods of suicide
Kill the person fast
- firearms
- jumping off a high place
- hanging
- carbon monoxide
- car crash
What are some “soft” methods of suicide
kill the person slowly
- slitting wrists
- taking pills
When determining the lethality of someone’s suicide plan, what things are you going to ask about
- Is there a specific plan with details (more details means higher risk)
- how lethal is the method (hard or soft)
- are the mean available to the person (do they have a gun, pills, a place to jump etc.)
What are the different levels of intervention for a patient who is suicidal
- primary
- secondary
- tertiary
What is primary intervention for suicide
activities that provide support and education to prevent serious situations
What is secondary intervention for suicide
treatment of a suicidal crisis. Use patients indecision to lead them towards not commiting suicide
What is tertiary intervention for suicide
Helping the families and loved ones of those who have committed suicide deal with the traumatic aftermath
Or help a person who had a failed attempt at suicide deal with the repercussions of their actions
What are some precautions taken for the psychiatric unit to prevent suicide
- use (and count) plastic utensils
- no private rooms
- keep room doors open
- jump-proof and hang-proof bathrooms
- remove harmful possessions
What are some non-suicidal self-injury behaviors
- cutting
- burning
- scratching
- biting
- hitting
- skin picking
- interference with wound healing
